Orchestra Musicians' Work Environment and Health Versus General Workforce.

OBJECTIVE: Our cross-sectional epidemiological study compared the work-environment harms and job uncertainties of orchestral musicians to those of the general population and their impact on health, work, and quality of life. METHODS: Musicians of all the Finnish domestic symphony orchestras and a population sample from the Finnish work force completed questionnaires, each group answering the same questions on their work environment and on health, ability to work, and quality of life. RESULTS: Noise disturbed the musicians 8 and poor lighting 22 times as often as these problems disturbed the controls. Musicians experienced mental violence or bullying considerably more often than did controls, with an odds ratio (95% confidence interval) of 3.0 (2.0-4.7). CONCLUSIONS: Noise issues and poor lighting are well-known problems for orchestra musicians, but mental violence or bullying are less well known. Research should focus on such areas.

Neurogenic Thoracic Outlet Syndrome with Supraclavicular Release: Long-Term Outcome without Rib Resection.

Our aim was to define clinical long-term outcome of surgery for neurogenic thoracic outlet syndrome without rib resection, and to find factors predicting long-term results. For the 94 patients, the main outcomes were pain, numbness, weakness, and upper-extremity function. The Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) survey, the Cervical-Brachial Symptom Questionnaire (CBSQ), and a numerical rating system served as functional outcome measures. Mean follow-up was 12.9 years. Preoperative pain diminished from 7.8 to 2.2, numbness from 7.4 to 4.0, and weakness from 7.3 to 3.8. Grip strength increased from 25.7 to 31.8 kg. QuickDASH averaged at follow-up 37.1 and CBSQ 51.5. No correlation appeared between smoking and long-term results regarding pain, numbness, weakness, or functioning. Positive TOS provocative tests or intraoperative anatomical findings like consistency of the scaleni muscles showed no correlation with outcome. 82% of female and 57% of male patients reported that aid from this surgery had been excellent or good; 69% reported that surgery helped considerably for at least a mean 9.9 years. The risk for worse self-reported long-term outcome was higher among men, but neither BMI nor age at surgery associated with self-reported outcome. Pain, numbness, and weakness significantly decreased and function improved after supraclavicular release without rib resection. We found no significant preoperative nor per-operative factors predicting long-term results.

Violists and Violinists Report More Intense Hand Pain on NRS Than Other Orchestra Musicians.

AIMS: Among musicians, string players have the highest prevalence for musculoskeletal overuse. Playing a violin or viola requires rapid, repetitive, and complicated movements of the hands and fingers. This cross-sectional study aimed to examine whether violin/viola, violin/cello, and violin/French horn players experience more intense musculoskeletal pain than other instrumentalists. METHODS: The study sample consisted of 590 orchestra musicians (354 male, 236 female, mean age 36 yrs). Self-administered questionnaires were used to assess pain of the back, neck, shoulder, face, jaw, and upper extremity. Pain intensity during the last 7 days was measured by an 11-point numeric rating scale (NRS) with a score from 0 to 10, as well as was disadvantage at work and leisure. RESULTS: Of the interviewed musicians, 20% presented playing-related musculoskeletal disorders at the time of the interview. Compared to other professional orchestra musicians, violin and viola players reported significantly more intense pain in the hand during the last week. Also, they had experienced more frequent neck pain ever and in 5 years than the others. During the past 30 days, violin and viola players had also perceived more harm in their upper limb joints. Violin/cello and violin/French horn players did not differ from the others. CONCLUSIONS: Our study showed that musicians playing the violin or viola have more intense hand pain and more frequent neck pain than other musicians, but these seem to disturb their daily tasks only a little.

Validity and internal consistency of the thoracic outlet syndrome index for patients with thoracic outlet syndrome.

BACKGROUND: No validated scales exist specifically for measuring quality of life (QoL) and functioning level in patients with thoracic outlet syndrome (TOS). This cross-sectional survey examined whether some items adopted from validated QoL scales could be suitable for patients with TOS. METHODS: To find an optimal thoracic outlet syndrome index (TOSI), a panel of 14 specialists experienced in treating TOS independently evaluated the relevance of 19 items adopted from scales used in other upper-extremity syndromes. After undergoing surgery for TOS, 52 patients rated the relevance of those items found by experts to be relevant. Content validity was measured by a content validity index, content validity ratio, and modified κ. The internal consistency of 15 retained items was assessed with the Cronbach α, and its construct validity was assessed by an exploratory factor analysis. RESULTS: Of the 19 items, 15 were considered relevant for TOS by the panelists, with an overall test content validity index of 0.93. The internal consistency of these 15 items was excellent. The exploratory factor analysis accompanied by a parallel analysis confirmed the uni-dimensionality of the TOSI. All 15 items that the panelists considered relevant were also items that the patients marked with scores over 7 points on an 11-point scale of relevance. CONCLUSION: The internally consistent, face- and content-valid TOSI scale is proposed for use in evaluating specifically the QoL in TOS patients, as well as improving future longitudinal studies comparing functioning before and after interventions or spontaneous recovery in TOS patients.

Long-Term Clinical Outcome After Titanium Lunate Arthroplasty for Kienböck Disease.

PURPOSE: Titanium lunate arthroplasty (TLA) for Kienböck disease was introduced in 1984 to address the silicone-wear particle problem common to silicone lunate implants. We sought to study the outcome of TLA. METHODS: We identified 11 patients from our hospital database who had undergone TLA between 2001 and 2010. We evaluated pain, range of motion (ROM), function, and radiological outcome at a mean 11 years after surgery. We compared preoperative ROM and radiological findings with final follow-up in the ipsilateral wrist and also made comparisons with the contralateral wrists. RESULTS: No implants were removed, and no wrist joints were fused. Pain on the visual analog scale averaged 0.5 at rest, 0.3 at night, and 2.7 during heavy exertion. Seven patients had no pain at rest and 9 had no pain at night. Range of motion reached 70% of that of the contralateral wrist, and strength reached 81%. The Disabilities of the Arm, Shoulder, and Hand (DASH) score averaged 9.6, optional DASH 9.7, and Mayo wrist score 67.7. Radiologically, only Ståhl and arthrosis indexes differed significantly between affected and unaffected wrists. Two patients had a dorsally dislocated implant, meaning that around 20% of our cases probably meet the criteria for failure. CONCLUSIONS: The longer-term results of TLA for stage III Kienböck disease are promising. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Validity and internal consistency of the Helsinki Serratus Palsy Index for patients with serratus palsy.

BACKGROUND: To our knowledge, no validated scales exist as yet for measuring quality of life and functioning level in patients with serratus palsy. This cross-sectional survey study examined whether a broadly validated Western Ontario Rotator Cuff Index (WORC) could be partially adapted for patients with serratus palsy. METHODS: The relevancy of WORC, 21 items, along with 4 additional new items, was tested by 95 patients with serratus palsy and a panel of 9 medical experts. Its content validity was measured by a content validity index (CVI), a content validity ratio (CVR), and a modified κ. The internal consistency of 11 retained items was assessed with the Cronbach α. Its construct validity was assessed by exploratory factor analysis. RESULTS: Of the 25 items, 11 were considered relevant (CVI ≥0.78) for serratus palsy by the panelists, with overall test CVI (S-CVI) of 0.86. The internal consistency of these 11 items was excellent, with a Cronbach α of 0.94. The exploratory factor analysis accompanied by a parallel analysis confirmed the unidimensionality of a new test. All except 2 items of WORC that were considered relevant by the panelists were also marked with scores of >5 by the patients on an 11-point scale of relevancy. CONCLUSIONS: Adapted from the WORC, the new 11-item Helsinki Serratus Palsy Index scale was internally consistent and face and content valid for serratus palsy patients.

Thoracic outlet syndrome.

It is important to remember the possibility of nonspecific thoracic outlet syndrome (TOS) when treating patients with neck and upper extremity symptoms. There are no specific diagnostic criteria for the syndrome. Diagnosis is based on symptoms, clinical examination and the ruling out of other causes. The first-line option of clinical care is conservative treatment, which in most cases is sufficient for the patient to regain normal functioning. However, some of the most difficult TOS patients need surgical treatment, especially when persistent symptoms have already begun in adolescence, and if compression of neural or vascular structures is thought to result from anatomical structures. Conservative treatment options are essential also for surgically treated patients.

Confirmatory Factor Analysis of the Finnish Job Content Questionnaire (JCQ) in 590 Professional Musicians.

BACKGROUND: Poorly functioning work environments may lead to dissatisfaction for the employees and financial loss for the employers. The Job Content Questionnaire (JCQ) was designed to measure social and psychological characteristics of work environments. OBJECTIVE: To investigate the factor construct of the Finnish 14-item version of JCQ when applied to professional orchestra musicians. METHODS: In a cross-sectional survey, the questionnaire was sent by mail to 1550 orchestra musicians and students. 630 responses were received. Full data were available for 590 respondents (response rate 38%).The questionnaire also contained questions on demographics, job satisfaction, health status, health behaviors, and intensity of playing music. Confirmatory factor analysis of the 2-factor model of JCQ was conducted. RESULTS: Of the 5 estimates, JCQ items in the "job demand" construct, the "conflicting demands" (question 5) explained most of the total variance in this construct (79%) demonstrating almost perfect correlation of 0.63. In the construct of "job control," "opinions influential" (question 10) demonstrated a perfect correlation index of 0.84 and the items "little decision freedom" (question 14) and "allows own decisions" (question 6) showed substantial correlations of 0.77 and 0.65. CONCLUSION: The 2-factor model of the Finnish 14-item version of JCQ proposed in this study fitted well into the observed data. The "conflicting demands," "opinions influential," "little decision freedom," and "allows own decisions" items demonstrated the strongest correlations with latent factors suggesting that in a population similar to the studied one, especially these items should be taken into account when observed in the response of a population.

Isolated serratus palsy etiology influences its long-term outcome.

HYPOTHESIS AND BACKGROUND: The cause of isolated serratus palsy is multifactorial, but evaluation of the mechanism of the injury indicates that the lesion to the long thoracic nerve is mechanical in origin in most cases. What is unknown, however, is how etiology influences its long-term outcome. We believed that overuse injuries may recover sooner and better than acute traumatic, infectious, or inflammatory injuries. METHODS: We determined the presumed etiology of isolated serratus palsy in 92 patients treated by brace or observation only and compared it with its long-term outcome after a mean follow-up of 18.1 years (range, 2.1-26.9) by measuring pain, range of motion, and winging of the scapula. RESULTS: Trauma preceded 22 (24%) of the cases, exertion 37 (40%), infection 14 (15%), and surgery/anesthesia 10 (11%). In 9 (10%) cases, no etiologic factor was evident. Serratus palsy preceded by infection recovered better than did cases with no infection, and those with palsy preceded by surgery/anesthesia had a poorer outcome than did those with no surgery (axilla, chest, or any other areas) or anesthesia. Those palsies caused by acute trauma or acute or chronic overuse/exertion had the same recovery course. DISCUSSION AND CONCLUSION: Etiology of isolated serratus palsy influenced long-term outcome less than we had expected. It seems, however, that palsies caused by infection recover better and those caused by surgery wherever in the body recover most poorly.

Is Alcohol Consumption Associated with Job Strain Among Professional Musicians?

OBJECTIVE: To assess the strength of the relationship between alcohol consumption and job strain experienced by professional musicians. METHODS: Cross-sectional survey among professional orchestra musicians (n=1,550, response rate 41%, data available for 590 respondents). The difference between groups with and without job strain was assessed by two-way analysis of variance. RESULTS: The median alcohol consumption was 48 g/wk (range 1-648, IQR 12-96). There were only 25 (4%) heavy drinkers, defined as people who consume >210 g of pure alcohol a week. The average frequency of drinking was 2.1 times/wk (SD 2.0, range 0-7). Of the respondents, 125 (21%) reported an elevated level of job strain as defined by the responses to Job Content Questionnaire. There was no significant interaction between the effects of gender and job strain on alcohol consumption: F(1, 586) = 0.82, p=0.365. Simple main effects analysis showed that males were consuming alcohol significantly more than females were (p=0.0005), but there were no differences between participants with elevated level of job strain compared with the rest of the sample (p=0.546). CONCLUSIONS: The amount of alcohol consumed was not associated with the presence or absence of perceived occupational strain among professional orchestra musicians.

Range of motion of diabetic frozen shoulder recovers to the contralateral level.

Objective To determine whether frozen shoulder heals equally well in patients with and without diabetes and whether dependency on insulin affects the outcome. Methods We retrospectively examined 178 patients with idiopathic frozen shoulder; 27 patients had diabetes. We evaluated range of motion, pain, and functional results. The mean follow-up was 9.7 years (SD, 7.1 years). Results In the presence of frozen shoulder, range of motion did not differ between patients with and without diabetes. At follow-up, range of motion in all directions of both the affected and unaffected shoulders of patients with diabetes was inferior to that of patients without diabetes. Among patients with diabetes, range of motion of the once-frozen shoulder reached the level of the unaffected shoulder. Patients with and without diabetes experienced similar pain except during exertion. The Constant-Murley score was not significantly different between the two groups, and insulin dependency did not lead to worse outcomes. Conclusion Frozen shoulder heals well in patients with diabetes.

Psychometric Properties of the Pain Numeric Rating Scale When Applied to Multiple Body Regions among Professional Musicians.

BACKGROUND: Despite the broad popularity of a numeric rating scale (NRS) its psychometric properties are not well known. The objective was to determine if there is any difference in the discrimination ability of the NRS when used for measuring pain severity separately in different body regions. METHODS: Cross-sectional survey study of 630 professional musicians. Item Response Theory (IRT) was used to define the psychometric properties of the NRS. RESULTS: The discrimination ability of the pain NRS was dependent on the body area to which it was applied. The discrimination was low 0.5 (95% CI 0.4. to 0.7) for the hand region and perfect for the shoulder and upper part of the neck- 3.2 (95% CI 1.2 to 5.2) and 10.5 (95% CI 10.0 to 10.9), respectively. Both shoulder and neck NRSs showed a great shift towards higher levels of pain severity meaning that the ability of the NRS to discriminate low levels of pain is poor. NRS scores obtained from all other regions did not demonstrate any discrimination ability. CONCLUSIONS: The pain NRS might have different psychometric properties depending on the body area to which it is applied. Overall, the modest discrimination ability of the pain NRS implies that it should be used in screening questionnaires with some reservations.

Patient outcome after surgical management of the spinal accessory nerve injury: A long-term follow-up study.

OBJECTIVES: A lesion in the spinal accessory nerve is typically iatrogenic: related to lymph node biopsy or excision. This injury may cause paralysis of the trapezius muscle and thus result in a characteristic group of symptoms and signs, including depression and winging of the scapula, drooped shoulder, reduced shoulder abduction, and pain. The elements evaluated in this long-term follow-up study include range of shoulder motion, pain, patients' satisfaction, delay of surgery, surgical procedure, occupational status, functional outcome, and other clinical findings. METHODS: We reviewed the medical records of a consecutive 37 patients (11 men and 26 women) having surgery to correct spinal accessory nerve injury. Neurolysis was the procedure in 24 cases, direct nerve repair for 9 patients, and nerve grafting for 4. Time elapsed between the injury and the surgical operation ranged from 2 to 120 months. The patients were interviewed and clinically examined after an average of 10.2 years postoperatively. RESULTS: The mean active range of movement of the shoulder improved at abduction 44° (43%) in neurolysis, 59° (71%) in direct nerve repair, and 30° (22%) in nerve-grafting patients. No or only slight atrophy of the trapezius muscle was observable in 75%, 44%, and 50%, and no or controllable pain was observable in 63%, 56%, and 50%. Restriction of shoulder abduction preceded deterioration of shoulder flexion. Patients' overall dissatisfaction with the state of their upper extremity was associated with pain, lower strength in shoulder movements, and occupational problems. CONCLUSION: We recommend avoiding unnecessary delay in the exploration of the spinal accessory nerve, if a neural lesion is suspected.

Open Surgical Treatment for Snapping Scapula Provides Durable Pain Relief, but so Does Nonsurgical Treatment.

BACKGROUND: Resection of the medial upper corner of the scapula is one option for treating patients with a painful chronic snapping scapula. However, the degree to which this procedure results in sustained relief of pain during long-term followup, and whether surgical treatment offers any compelling advantages over nonsurgical approaches at long-term followup, are not known. QUESTIONS/PURPOSES: We asked: (1) At long-term followup after surgical treatment of a painful snapping scapula, did patients' pain decrease? (2) Did scapulocostal crepitation improve? (3) Did patients return to work? METHODS: Between 1971 and 1992, 15 patients underwent surgery by one surgeon for persistent (> 1 year) and severely painful crepitus around the superomedial scapula that did not respond to nonsurgical approaches. The procedure consisted of an open resection of the superomedial corner of the scapula and release of the levator scapulae muscle. Patients treated surgically were compared with a group of nine patients treated nonsurgically between 1975 and 1997; their treatments included temporary physiotherapy, massage, and NSAIDs. In general, the patients treated nonsurgically presented with less pain. However, during much of this study period, objective pain and functional scales were not in common use, and so baseline scores were not available. Of the 15 patients treated surgically, nine participated in a clinical and questionnaire survey at a mean of 22 years (range, 16-35 years), and 12 participated in a questionnaire survey a mean 27 years after surgery (range, 23-43 years). Of the nine patients treated nonsurgically, seven participated in a clinical followup and questionnaire survey at a mean followup of 16 years (range, 10-25 years), and all nine completed a questionnaire survey at a mean of 22 years (range, 17-33 years). Patient age at onset of symptoms was a mean of 27 years. The clinical followup and questionnaires focused on pain, crepitation, and work status. RESULTS: With the numbers available, there was no difference in pain scores between patients treated surgically and those treated nonsurgically (mean VAS pain with exertion 0.8 ± 1.3 versus 1.5 ± 1.6; p = 0.357); in fact, pain scores were quite low in both groups. Pain improved promptly in seven of 12 patients treated surgically, but lasted for at least several years in all patients treated nonsurgically. Crepitus persisted variably in both groups at final followup, with no apparent difference between the groups in terms of its frequency, but it was not consistently associated with pain at final followup in either group (six of 12 patients treated surgically, all painless; and all of seven clinically examined patients treated nonsurgically, two without pain, had crepitus at latest followup; p = 0.004), whereas at initial presentation, the crepitus had been painful in all patients. All patients in both groups had returned to work after surgery or the first consultation. CONCLUSIONS: Carefully selected patients who undergo this procedure appear to obtain sustained relief of painful crepitus at long term, but so do patients treated nonsurgically. Since the decision to treat these patients surgically was somewhat subjective, and since patients treated nonsurgically did so well (although the surgically treated patients improved faster), we cannot conclude that surgery is better than nonsurgical treatment. Multicenter comparative studies with carefully applied indications are needed. LEVEL OF EVIDENCE: Level III, therapeutic study.

Scapular Bracing is Effective in Some Patients but Symptoms Persist in Many Despite Bracing.

BACKGROUND: A scapular-protecting brace is one option for treating patients with a winging scapula in isolated serratus palsy. However, outcomes after brace treatment have been reported in only a few studies, and to our knowledge, none has results reported at long-term beyond 10 years. QUESTIONS/PURPOSE: We asked: (1) What was the average length of time patients wore the brace? (2) Did scapular winging and ROM improve with brace treatment? (3) Was pain decreased? (4) Did the duration of symptoms before brace treatment influence the outcome? PATIENTS AND METHODS: Between 1980 and 1999, we treated 110 patients with a scapular-protecting brace. General indications for this treatment included electroneuromyography-verified isolated serratus palsy, 3 cm or greater scapular winging, and limited ROM. For patients with scapular winging less than 3 cm we used observation and avoidance of all heavy work or lifting. Of the patients treated with a brace, 55 (50%) were available at a minimum followup of 10 years (mean, 22 years; range, 10-28 years). Mean patient age was 30 years at the onset of symptoms (range, 15-52 years). Brace use was based on patient self-report, and we determined the degree of scapular winging and ROM clinically and level of pain by chart review before and after treatment. RESULTS: The brace was applied a mean 6 months (median, 5 months) after onset of symptoms. Mean duration of brace use was 10 months for 12 hours per day. Winging of the scapula, measured in 90° flexion without resistance, disappeared in 35 patients (64%) with brace use. Flexion averaged 153° and abduction 168°. Ten patients (18%) were pain-free during exertion and 18 (33%) at rest. Pain at rest was present in 37 patients (67%); of those, it was present only seldom in 15 (27%), sometimes present in 21 (38%), and one patient (2%) experienced continuous pain at rest despite brace treatment. With the number of patients available, there were no differences between patients who started brace treatment early (within 6 months of onset of symptoms) and those who started later (more than 6 months after symptom onset) in terms of improvement of scapular winging in flexion at 90° with resistance (mean, 1.2±2.0 cm vs 1.7±2.3 cm; p=0.415; 95% CI, -1.6 to 0.7), better flexion (mean, 156°±17° flexion vs 149°±28° flexion; p<0.253; 95% CI, -5 to 19), or improvement in other parameters that we measured. CONCLUSIONS: Compliance was high for scapular-protecting brace treatment in patients with serratus palsy but recovery was incomplete for many patients, most of whom still had some pain and a large proportion still had some degree of scapular winging. We continue to use scapular bracing for treating patients who have 3 cm or more scapular winging and limited ROM, and whose work or hobbies demand motions causing winging, although we counsel our patients that recovery is likely to be incomplete. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Motion and pain relief remain 23 years after manipulation under anesthesia for frozen shoulder.

BACKGROUND: Manipulation under anesthesia (MUA) as treatment for idiopathic frozen shoulder increases motion, provides pain relief, and restores function, but it is unclear whether the improvements persist long term. QUESTIONS/PURPOSES: We therefore investigated whether (1) ROM was restored, (2) pain was relieved, and (3) function was restored and maintained after several decades in patients with idiopathic frozen shoulder treated by MUA. METHODS: We followed 15 patients (16 shoulders; 12 in women) at 3 months, 7 years, and 19 to 30 years after MUA for frozen shoulder. Their mean age at MUA was 48.5 years. Four patients had diabetes. The time between the onset of symptoms and manipulation averaged 7.6 months. We determined pain by a patient-generated VAS (range, 0-10; 0=none, 10=maximal). We recorded ROM and Constant-Murley scores at last followup. RESULTS: At 7 years, improvement had occurred in forward flexion to 155°, abduction to 175°, external rotation to 51°, and internal rotation to the T7 level. During the next 16 years, ROM deteriorated by 8° to 23° at last followup, but still equaled ROM of the contralateral shoulder. On the VAS, pain at last followup averaged 1.5 with exertion, 0.3 at rest, and 0.8 at night. The Constant-Murley score was 70 (range, 34-88); 12 patients reached the age- and sex-adjusted normal Constant-Murley score. CONCLUSIONS: In this group of patients treatment of idiopathic frozen shoulder by MUA led to improvement in shoulder motion and function at a mean 23 years after the procedure. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Rotator cuff integrity correlates with clinical and functional results at a minimum 16 years after open repair.

BACKGROUND: Recurrent or persistent defects in the rotator cuff after its repair are common. Short- and medium-term surveys have revealed, after open repair, patients with an intact rotator cuff have increased function and ROM. However, no long-term studies have verified cuff integrity on MR arthrography or correlated it with clinical and functional outcomes. QUESTIONS/PURPOSES: We evaluated long-term cuff integrity and fatty infiltration after open repair using MR arthrography and determined whether these findings correlated with clinical and functional results. METHODS: Using MR arthrography, we retrospectively evaluated 67 patients (48 men, 19 women) who underwent open rotator cuff repair between 1980 and 1989. Their mean age at surgery was 52 years. Minimum followup was 16 years (mean, 20 years; range, 16-25 years). RESULTS: The retear rate was 94%, and mean size of rerupture was 3.5 × 3.6 cm (ranges, 0.5-5.0 cm × 0.5-5.2 cm; median, 4 × 4 cm). The remaining four patients had a partial supraspinatus tendon tear. Fatty infiltration was marked in the supraspinatus and infraspinatus tendons. Cuff integrity correlated with clinical results: active external rotation and forward flexion, and flexion, abduction, and external rotation strengths, were better in patients with an intact rotator cuff or a small retear of 4 cm(2) or less than in patients with larger tears. Cuff integrity also correlated with functional results. CONCLUSIONS: Rotator cuff integrity was lost in 94% of patients after a minimum followup of 16 years. Cuff integrity correlates well with clinical and functional results even several years postoperatively. A large retear seems to be the most important factor in deteriorating long-term clinical and functional results after open rotator cuff repair. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

The natural course of serratus palsy at 2 to 31 years.

BACKGROUND: The natural course of isolated serratus palsy is obscure. Residual winging, muscle weakness, and fatigability reportedly occur in half of the patients. Because we believed isolated serratus palsy might have a better natural course than earlier thought, we evaluated our long-term records. QUESTIONS/PURPOSES: We determined duration of symptoms and whether scapular winging, ROM, and pain recover or persist after isolated serratus palsy without any particular treatment. METHODS: We retrospectively reviewed 37 patients with isolated serratus palsy treated by observation without any brace or surgery. We determined the degree of scapular winging, ROM, and pain. The minimum followup was 2 years (median, 18 years; range, 2-31 years) after onset of symptoms. RESULTS: The duration of scapular winging averaged 16 months (range, 2-30 months). Winging of the scapula disappeared in 29 (78%) of the patients, flexion recovered to normal in 30 (82%) and abduction in 33 (89%). Of the 37 patients, 11 (30%) were pain-free; pain at rest was absent from 17 (46%), occurred seldom in seven (19%), and was temporary in 12 (32%); one patient had pain at rest continuously. None of the patients desired other treatment such as a brace or surgery. CONCLUSIONS: The natural course of isolated serratus palsy in clinically mild cases is not as favorable as we had expected. Symptoms mostly recover in 2 years, but at least one-fourth of the patients will have long-lasting symptoms, especially pain. We could identify no factors to allow us to appropriately choose patients with serratus palsy for observation only.

The natural history of idiopathic frozen shoulder: a 2- to 27-year followup study.

BACKGROUND: The natural history of spontaneous idiopathic frozen shoulder is controversial. Many studies claim that complete resolution is not inevitable. Based on the 40-year clinical experience of the senior author, we believed most patients with idiopathic frozen shoulder might have a higher rate of resolution than earlier thought. QUESTIONS/PURPOSES: We determined the length of symptoms, whether spontaneous frozen shoulder recovered without any treatment, and whether restored ROM, pain relief, and function persisted over the long term. METHODS: We retrospectively reviewed 83 patients treated for frozen shoulder (84 shoulders; 56 women) 2 to 27 years (mean, 9 years) after initial consultation. The mean age at onset of symptoms was 53 years. Fifty-one of the 83 patients (52 shoulders) were treated with observation or benign neglect only (untreated group), and 32 had received some kind of nonoperative treatment before the first consultation with the senior author (nonoperative group). We also evaluated all 20 patients (22 shoulders; 13 women) with spontaneous frozen shoulder who underwent manipulation under anesthesia during the same time (manipulation group). The mean age of these patients was 49 years. The minimum followup was 2 years (mean, 14 years; range, 2-24 years). We determined duration of the disease, pain levels, ROM, and Constant-Murley scores. RESULTS: The duration of the disease averaged 15 months (range, 4-36 months) in the untreated group, and 20 months (range, 6-60 months) in the nonoperative group. At last followup the ROM had improved to the contralateral level in 94% in the untreated group, in 91% in the nonoperative group, and in 91% in the manipulation group. Fifty-one percent of patients in the untreated group, 44% in the nonoperative group, and 30% in the manipulation group were totally pain free at rest, during the night, and with exertion. Pain at rest was less than 3 on the VAS in 94% of patients in the untreated group, 91% in the nonoperative group, and 90% of the manipulation group. The Constant-Murley scores averaged 83 (86%) in the untreated group, 81 (77%) in the nonoperative group, and 82 (71%) in the manipulation group, reaching the normal age- and gender-related Constant-Murley score. CONCLUSIONS: We found 94% of patients with spontaneous frozen shoulder recovered to normal levels of function and motion without treatment. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

[An unusual etiology for pain in the back, hip and leg in a young woman]. / Nuoren naisen mystinen alaselkä-lonkka-alaraajakipu.

We present a 28-year old woman, suffering from low back and right leg pain for 5 years, with motor and sensory deficits of the leg. Disc herniation, hip related pain, depression, and even an osteoid osteoma were suspected during the years, and several imaging studies had been undertaken. Based on an ENMG-study a lesion affecting the right L5-nerve root distal to the ganglion was suspected. On a pelvic MRI a nonenhancing tumor of the right L5-root was seen. The tumor was resected operatively. On histologic examination an uncommon granulocellular tumor was diagnosed. The patient recovered almost completely.